Experience with H anastomosis and its perioperative management protocol in minimally invasive esophagectomy: a propensity score-matched comparison with stapled non-enhanced recovery after surgery pathway.

BACKGROUND

H anastomosis is an emerging esophagogastric reconstruction technique that has shown promising perioperative results. However, real-world comparative evidence, particularly from rigorously matched cohorts, remains limited. Therefore, the present study aimed to compare short-term postoperative recovery metrics between the H anastomosis pathway and a stapled anastomosis pathway using propensity score matching (PSM).

METHODS

This single-center retrospective study compared patients who underwent H anastomosis pathway between October 2024 and July 2025 (n=100) with those who received stapled anastomosis pathway between October 2023 and July 2024 (n=102). PSM was applied in a 1:1 ratio (75 matched pairs) based on age, sex, body mass index (BMI), and neoadjuvant therapy (NAT). Postoperative hospital stay (PHS) and postoperative fasting duration (PFD), modeled as overdispersed count variables, were analyzed using negative binomial regression. For low-frequency events-including severe pulmonary infection (SPI), reinsertion, and anastomotic leakage (AL)-Firth's penalized logistic regression was used to reduce small-sample bias. Binary postoperative outcomes-including hypoalbuminemia, fever, high-grade fever, tachycardia, and atrial fibrillation (AF)-were evaluated using standard logistic regression.

RESULTS

The H anastomosis pathway group demonstrated significantly shorter PHS and PFD (PHS: 10.27±4.19 vs. 17.29±6.95 days, P<0.001; PFD: 1.64±1.29 vs. 9.99±6.02 days, P<0.001) and lower incidences of postoperative fever, high-grade fever, AF, and hypoalbuminemia compared with the stapled anastomosis pathway group. These associations remained robust after adjustment for smoking and alcohol history and major comorbidities.

CONCLUSIONS

Although superiority cannot yet be claimed, our findings indicate that H anastomosis, when implemented together with its coordinated perioperative management protocol, provides a stable and feasible enhanced recovery after surgery (ERAS) oriented pathway for minimally invasive esophagectomy (MIE).